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General NPI Number Information
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NPI Number | 1285412007
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Entity Type | Organization
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Legal Business Name | DE LA PENA EYE CLINIC, A MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 09/21/2023
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Last Update Date | 09/21/2023
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Provider Practice Location Address
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Address Line | 1760 TERMINO AVE STE 306
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City | LONG BEACH
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State | CA
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Zip | 90804-2182
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Country | US
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Telephone | 323-728-5500
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Fax |
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Provider Business Mailing Address
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Address Line | ATTN LICENSING, 401 COMMERCE STREET SUITE 600
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City | NASHVILLE
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State | TN
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Zip | 37219-2518
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Country | US
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Telephone | 615-760-6593
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Fax |
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Authorized Official
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Title or Position | PRESIDENT, BOARD OF MANAGERS
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Name | GEORGE ARD
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Credential |
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Telephone | 615-717-7135
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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